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Robson B, Deed G, Phoon RK. Improving the Detection and Management of Kidney Health in Primary Care. J Patient Exp 2024; 11:23743735241256464. [PMID: 38882946 PMCID: PMC11179444 DOI: 10.1177/23743735241256464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024] Open
Abstract
Chronic kidney disease (CKD) is a major cause of morbidity and mortality, contributing to approximately 20 000 deaths in 2021 in Australia. Importantly, progression of CKD can be substantially reduced if it is detected and treated early. Here we present the perspectives of a general practitioner (primary care physician), a nephrologist and a patient advocate on how the diagnosis and management of CKD in primary care could be improved. Early detection and treatment of CKD are impeded by limited patient awareness and knowledge, communication challenges between patients and doctors, and psychosocial issues, with these factors also interacting with, and exacerbating, each other. We make the following recommendations to help improve outcomes in patients with CKD: (1) identifying people at increased risk of CKD and ensuring they have a complete kidney health check (including estimated glomerular filtration rate, urine albumin-creatinine ratio and a blood pressure check) every 1-2 years; (2) using simple, nonconfrontational language and supportive resources to communicate with patients about kidney health; (3) implementing early treatment to slow the progression of CKD and avoid adverse cardiovascular disease outcomes; and (4) asking patient-orientated questions to support shared decision-making and empower patients to be active partners in their healthcare. We acknowledge that limited time is a major barrier to implementing these recommendations in primary care. Utilizing the expertise of the whole practice team, and adopting supportive technology to introduce efficiencies, are likely to be of benefit. By adopting these recommendations, we believe general practitioners have the opportunity to drive improved outcomes and quality of life for people living with CKD in Australia.
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Affiliation(s)
| | - Gary Deed
- Healthcare Plus Medical Centre, Coorparoo, Queensland, Australia
- Monash University, Melbourne, Victoria, Australia
| | - Richard Ks Phoon
- Department of Renal Medicine, Centre for Transplant and Renal Research, Westmead Hospital, Westmead, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Chu CD, Dohan D, Estrella MM, Shlipak MG, Tuot DS. Primary care clinician perspectives on automated nephrology e-consults for diabetic kidney disease: a pre-implementation qualitative study. BMC PRIMARY CARE 2024; 25:197. [PMID: 38834994 PMCID: PMC11149280 DOI: 10.1186/s12875-024-02454-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 05/30/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Many patients with diabetic kidney disease (DKD) do not receive evidence-based, guideline-recommended treatment shown to reduce DKD progression and complications. Proactive electronic consultations (e-consults) are an emerging intervention strategy that could potentially allow nephrologists to provide timely and evidence-based guidance to primary care providers (PCPs) engaged in early DKD care. METHODS The objective of this study was to explore perspectives about potential barriers and facilitators associated with a proactive e-consult program to improve DKD care delivery. We conducted semi-structured qualitative interviews with PCPs across three different health systems. Interview transcripts were reviewed in a rapid qualitative analysis approach to iteratively identify, refine, and achieve consensus on a final list of themes and subthemes. RESULTS A total of 18 interviews were conducted. PCPs across all sites identified similar challenges to delivering guideline-recommended DKD care. PCPs were supportive of the proactive e-consult concept. Three major themes emerged surrounding (1) perceived potential benefits of proactive e-consults, including educational value and improved specialist access; (2) concerns about the proactive nature of e-consults, including the potential to increase PCP workload and the possibility that e-consults could be seen as documenting substandard care; and (3) leveraging of care teams to facilitate recommended DKD care, such as engaging clinic-based pharmacists to implement specialist recommendations from e-consults. CONCLUSION In this pre-implementation qualitative study, PCPs noted potential benefits and identified concerns and implementation barriers for proactive e-consults for DKD care. Strategies that emerged for promoting successful implementation included involving clinic support staff to enact e-consult recommendations and framing e-consults as a system improvement effort to avoid judgmental associations.
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Affiliation(s)
- Chi D Chu
- Department of Medicine, University of California, San Francisco, San Francisco, CA, 94110, USA.
- Department of Medicine, Division of Nephrology, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, 1001 Potrero Ave, Bldg 100, Rm 342, San Francisco, CA, 94110, USA.
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco VA Health Care System, San Francisco, CA, USA.
| | - Daniel Dohan
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA
| | - Michelle M Estrella
- Department of Medicine, University of California, San Francisco, San Francisco, CA, 94110, USA
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco VA Health Care System, San Francisco, CA, USA
| | - Michael G Shlipak
- Department of Medicine, University of California, San Francisco, San Francisco, CA, 94110, USA
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco VA Health Care System, San Francisco, CA, USA
| | - Delphine S Tuot
- Department of Medicine, University of California, San Francisco, San Francisco, CA, 94110, USA
- Department of Medicine, Division of Nephrology, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, 1001 Potrero Ave, Bldg 100, Rm 342, San Francisco, CA, 94110, USA
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Padiyar A, Sarabu N, Ahlawat S, Thatcher EJ, Roeper BA, Anantharamakrishnan A, Runnels P, Bahner C, Lang SE, Barnett TD, Raghuwanshi Y, Pronovost PJ. Bridging the Evidence and Practice Gap in Chronic Kidney Disease: A System Thinking Approach to Population Health. Popul Health Manag 2024; 27:151-159. [PMID: 38800940 DOI: 10.1089/pop.2023.0275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
Chronic kidney disease (CKD) is common, costly, and life-limiting, requiring dialysis and transplantation in advanced stages. Although effective guideline-based therapy exists, the asymptomatic nature of CKD together with low health literacy, adverse social determinants of health, unmet behavioral health needs, and primary care providers' (PCP) limited understanding of CKD result in defects in screening and diagnosis. Care is fragmented between PCPs and specialty nephrologists, with limited time, expertise, and resources to address systemic gaps. In this article, the authors define how they classified defects in care and report the current numbers of patients exposed to these defects, both nationally and in their health system Accountable Care Organization. They describe use of the health system's three-pillar leadership model (believing, belonging, and building) to empower providers to transform CKD care. Believing entailed engaging individuals to believe defects in CKD care could be eliminated and were a collective responsibility. Belonging fostered the creation of learning communities that broke down silos and encouraged open communication and collaboration between PCPs and nephrologists. Building involved constructing a fractal management infrastructure with transparent reporting and shared accountability, which would enable success in innovation and transformation. The result is proactive and relational CKD care organized around the patient's needs in University Hospitals Systems of Excellence. Systems of excellence combine multiple domains of expertise to promote best practice guidelines and integrate care throughout the system. The authors further describe a preliminary pilot of the CKD System of Excellence in primary care.
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Affiliation(s)
- Aparna Padiyar
- Division of Nephrology, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Nagaraju Sarabu
- Division of Nephrology, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Shruti Ahlawat
- Division of Nephrology, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Esther J Thatcher
- Population Health, University Hospitals Health System, Shaker Heights, Ohio, USA
| | - Brooke A Roeper
- Population Health, University Hospitals Health System, Shaker Heights, Ohio, USA
| | | | - Patrick Runnels
- Population Health, University Hospitals Health System, Shaker Heights, Ohio, USA
- Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Carol Bahner
- Care Management Population Health, University Hospitals Health System, Shaker Heights, Ohio, USA
| | - Sarah E Lang
- Department of Family Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Tyler D Barnett
- Data Sciences & Analytics, Population Health, University Hospitals Health System, Shaker Heights, Ohio, USA
| | | | - Peter J Pronovost
- University Hospitals Health System, Shaker Heights, Ohio, USA
- Department of Anesthesia and Critical Care Medicine, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
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Stine JG, Medic N, Pettersson B, Venerus M, Blau JE. The health care experience of adults with metabolic dysfunction-associated steatohepatitis and influence of PNPLA3: A qualitative study. Hepatol Commun 2024; 8:e0451. [PMID: 38780312 PMCID: PMC11124700 DOI: 10.1097/hc9.0000000000000451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/06/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Metabolic dysfunction-associated steatohepatitis (MASH) is a progressive form of metabolic dysfunction-associated steatotic liver disease, for which there is limited information about patient experience, including the patient journey. METHODS In this study, we conducted interviews with patients with MASH to qualitatively evaluate the patient journey and help elucidate the experiences of this patient population. We also investigated if the patatin-like phospholipase domain-containing protein 3 (PNPLA3) I148M variant (non-Hispanic) or being of Hispanic ethnicity may influence patient experiences because these 2 subgroups develop advanced liver disease more frequently than other patient groups. RESULTS One-to-one interviews were conducted with 28 adults (with PNPLA3 I148M genetic variant, n = 10; Hispanic, n = 8) living in the United States who had been diagnosed with MASH with liver fibrosis. Patients were asked open-ended questions about their experiences before, at, and after their diagnosis. The data collected found that patients experienced a long process of misdiagnoses before their diagnosis of MASH, a lack of clear information provided by clinicians, and limited accessibility to support groups. Hispanic patients reported "impact on family/friends" (75%) and "fear of disease progression" (75%) more frequently than the other patient cohorts interviewed. This is the first report of "fear of progression" in patients with MASH. No patients who were White and had the PNPLA3 I148M variant reported nausea/vomiting, in contrast to other patient cohorts. CONCLUSIONS This qualitative study identified key aspects of the patient journey that are important for clinical providers and medical teams to recognize. We also propose a new algorithm that could be developed to help screen relatives of patients who are found to carry the PNPLA3 I148M variant.
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Affiliation(s)
- Jonathan G. Stine
- Department of Medicine, Division of Gastroenterology and Hepatology, The Pennsylvania State University Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
- Fatty Liver Program, Pennsylvania State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
- Liver Center, The Pennsylvania State University Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
- Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
- Cancer Institute, The Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Nenad Medic
- Patient Centered Science, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals Medical, AstraZeneca, Cambridge, UK
| | - Billie Pettersson
- Patient Centered Science, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
| | | | - Jenny E. Blau
- Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland, USA
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Bates A, Letton ME, Arnold R, Lambert K. Barriers and enablers to exercise in kidney transplant recipients: Systematic review of qualitative studies. J Ren Care 2024. [PMID: 38806247 DOI: 10.1111/jorc.12497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/30/2024] [Accepted: 05/06/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Exercise has the potential to reduce the susceptibility to comorbidity and cardiovascular disease in kidney transplant recipients. However, kidney transplant recipients report lower levels of exercise compared to the general population, prompting an investigation into the barriers and enablers to exercise in this transplant cohort. OBJECTIVES This systematic review aimed to explore and map the barriers and enablers to exercise in kidney transplant recipients. METHODS Seven electronic databases were systematically searched. Themes were synthesised and then deductively categorised using the Theoretical Domains Framework. RESULTS Eleven studies were included in the review. Commonly reported barriers to exercise were lack of exercise guidance (n = 9 studies), physical limitations (n = 5 studies) and a fear of harming the kidney (n = 7 studies). Enablers were a desire to return to normality (n = 5 studies), physical and mental benefits (n = 3 studies), goal setting and tracking improvements (n = 3 studies). At the local level, barriers identified by kidney transplant recipients were a lack of knowledge, fear of injuring the kidney, bad weather and physical limitations. Perceived enablers were already living an active lifestyle, mental benefits, exercise preferences and social support. CONCLUSION Key findings of this research were an increased demand for specific/explicit exercise information regarding type and intensity, and personalised guidance and support for kidney transplant recipients after transplantation. These findings can be used to inform the development of exercise resources and interventions for kidney transplant recipients and their health care professionals within the local community and at a greater level.
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Affiliation(s)
- Alexander Bates
- School of Medical, Indigenous & Health Sciences, University of Wollongong, Wollongong, New South Wales, Australia
| | - Meg E Letton
- School of Medical, Indigenous & Health Sciences, University of Wollongong, Wollongong, New South Wales, Australia
| | - Ria Arnold
- School of Medical, Indigenous & Health Sciences, University of Wollongong, Wollongong, New South Wales, Australia
- School of Health Sciences, University of New South Wales, Sydney, New South Wales, Australia
- Department of Renal Medicine, Concord Repatriation and General Hospital, Sydney, New South Wales, Australia
- Concord Clinical School, University of Sydney, New South Wales, Australia
| | - Kelly Lambert
- School of Medical, Indigenous & Health Sciences, University of Wollongong, Wollongong, New South Wales, Australia
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Pintado-Outumuro E, Morin-Fraile V, Salvador-González B, Benito L, Julve-Ibáñez M, Sancho-Campos MP, Alves-Tafur C, Lumillo-Gutiérrez I. Exploring the factors influencing evidence-based approaches to advanced chronic kidney disease: a qualitative study involving nurses and physicians. BMC PRIMARY CARE 2024; 25:177. [PMID: 38773496 PMCID: PMC11107048 DOI: 10.1186/s12875-024-02418-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 05/06/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Advanced chronic kidney disease (ACKD) is associated with a high risk of adverse cardiovascular and renal events and has a significant impact on quality of life and life expectancy. Several studies have identified areas for improvement in their management in primary care. Some professional and environmental factors can act as key barriers to appropriate care. OBJECTIVE To analyse attitudes, subjective norms, and perceived behavioural control among primary care professionals related to the implementation of an evidence-based approach for individuals with ACKD in primary care. METHODOLOGY This was a qualitative study using an interpretative phenomenological approach based on the theory of planned behaviour. Two aspects of the evidence-based approach were explored: the implementation of clinical practice guidelines and the utilisation of electronic kidney disease records within the scope of this study. Primary care nurses and physicians participated in a previous pilot interview and five focus groups. Subsequently, a thematic analysis of the gathered data was conducted. FINDINGS Thirty-three primary care professionals participated. The emerging themes included: experiences in the management of ACKD (highlighting a distinct profile of older, frail patients with comorbidities masking CKD and a CKD follow-up primarily focused on analytical monitoring and drug adjustment); factors in the professional environment influencing the use of scientific evidence (such as time constraints, excessive electronic health records, and unfamiliar reference guidelines); attitudes towards the application of recommendations on ACKD (recognising limitations of computer systems despite considering them as guidance); and capacities to implement evidence-based recommendations (acknowledging formative needs and challenges in coordinating care with nephrology services). CONCLUSIONS Several psychological elements identified through the TBP hinder the adequate implementation of an evidence-based approach for individuals with CKD. Attitudes have been identified as factors modulating the use of standardised electronic records. Instead, subjective norms (influences from the professional environment) and perceived behavioral control (perception of capabilities) acted as barriers to the proper application of clinical practice guidelines and standardised records. IMPLICATIONS FOR PRACTICE Strategies aimed at optimising the management of people with ACKD should focus not only on training but also on improving attitudes, organisational structures, IT systems and coordination between primary care and nephrology.
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Grants
- SLT021/21/000031 Departamento de Salud, Generalitat de Cataluña , España
- SLT021/21/000031 Departamento de Salud, Generalitat de Cataluña , España
- SLT021/21/000031 Departamento de Salud, Generalitat de Cataluña , España
- SLT021/21/000031 Departamento de Salud, Generalitat de Cataluña , España
- SLT021/21/000031 Departamento de Salud, Generalitat de Cataluña , España
- SLT021/21/000031 Departamento de Salud, Generalitat de Cataluña , España
- SLT021/21/000031 Departamento de Salud, Generalitat de Cataluña , España
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Affiliation(s)
- Elena Pintado-Outumuro
- Primary Care Center El Pla. Servei d'Atenció Primària Baix Llobregat Centre, Atenció Primària Metropolitana Sud, Institut Català de la Salut, Sant Feliu de Llobregat, Barcelona, 08980, Spain
- Research Group On Disease, Cardiovascular Risk and Lifestyles in Primary Care, Institut Universitari d'Investigació en Atenció Primària (IDIAP) Jordi Gol, Barcelona, 08007, Spain
| | - Victoria Morin-Fraile
- Department of Public Health, Mental Health and Maternal and Child Health Nursing. Faculty of Nursing, University of Barcelona. Pavelló de Govern, 3Rd Floor, L'Hospitalet de Llobregat, Barcelona, 08907, Spain
- Research Group On Environments and Materials for Learning, Universitat de Barcelona, Barcelona, Spain
| | - Betlem Salvador-González
- Unitat de Suport a la Recerca Metropolitana Sud, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), L'Hospitalet de Llobregat, Barcelona, 08907, Spain
- Research Group On Disease, Cardiovascular Risk and Lifestyles in Primary Care, Institut Universitari d'Investigació en Atenció Primària (IDIAP) Jordi Gol, Barcelona, 08007, Spain
| | - Llúcia Benito
- Fundamental and Clinic Nursing Department, Faculty of Nursing, University of Barcelona, Pavelló de Govern, 3Rd Floor, L'Hospitalet de Llobregat, Barcelona, 08907, Spain
- IDIBELL, Bellvitge Biomedical Research Institute, Avinguda de la Gran Via, 199, L'Hospitalet de Llobregat, Barcelona, 08908, Spain
| | - Maricel Julve-Ibáñez
- Primary Care Center El Castell, Servei d'Atenció Primària Delta del Llobregat, Atenció Primària Metropolitana Sud, Institut Català de la Salut, Castelldefels, 08860, Barcelona, Spain
| | - M-Pilar Sancho-Campos
- Primary Care Center Sant Ildefons. Servei d'Atenció Primària Baix Llobregat Centre, Atenció Primària Metropolitana Sud, Institut Català de la Salut, Cornellà de Llobregat, Barcelona, 08940, Spain
| | - Carolina Alves-Tafur
- Primary Care Center Montclar and Primary Care Center Camps Blancs. Servei d'Atenció Primària Baix Llobregat Centre, Atenció Primària Metropolitana Sud, Institut Català de la Salut, Sant Boi de Llobregat, Barcelona, 08830, Spain
| | - Iris Lumillo-Gutiérrez
- Department of Public Health, Mental Health and Maternal and Child Health Nursing. Faculty of Nursing, University of Barcelona. Pavelló de Govern, 3Rd Floor, L'Hospitalet de Llobregat, Barcelona, 08907, Spain.
- Research Group On Disease, Cardiovascular Risk and Lifestyles in Primary Care, Institut Universitari d'Investigació en Atenció Primària (IDIAP) Jordi Gol, Barcelona, 08007, Spain.
- Research Group On Environments and Materials for Learning, Universitat de Barcelona, Barcelona, Spain.
- Chronicity and Complexity Care Unit (UTACC) Baix Llobregat Centre, Atenció Primària Metropolitana Sud, Institut Català de la Salut, Cornellà de Llobregat, 08940, Spain.
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Oude Engberink A, Tessier G, Kamil I, Bourrel G, Moranne O. General practitioners' representation of early-stage CKD is a barrier to adequate management and patient empowerment: a phenomenological study. J Nephrol 2024; 37:379-390. [PMID: 38227278 DOI: 10.1007/s40620-023-01838-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 11/18/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND In high-income countries, chronic kidney disease (CKD) affects over 10% of the population. Identifying these patients early is a priority, especially as new treatments are available to reduce the risk of cardiovascular and renal morbidity. We aimed at understanding the management and care pathway of patients with early-to-moderate CKD defined as an estimated glomerular filtration rate (eGFR) ≥ 45 mL/min/1.73 m2 (CKD-EPI), by analyzing the experience of general practitioners in a region in France. METHODS This qualitative semiopragmatic phenomenological study analyzed in-depth interviews held with a purposive sample (age, gender, training, type of practice, rural/urban context) of 24 general practitioners, with triangulation of research until data saturation. RESULTS From diagnostic, etiological and prognostic viewpoints, the general practitioners enrolled in our study perceived CKD as a complex, poorly-defined clinical entity in asymptomatic and multimorbid patients. They distinguished it from a rare condition they considered as 'mainly renal'. The fact that they did not perceive early-stage CKD as a disease was a hindrance to patient care, which should protect the kidneys with a preventive approach. Indeed, general practitioners perceived CKD patient management as a pathway requiring a personalized, integrative model, common to all chronic diseases, without necessarily involving a nephrologist, at least in the early stages. CONCLUSIONS This study shows how the general practitioners' representations influence their attitudes and interventions. Clarifying the concept of early-stage CKD by taking factors like age and etiology into account would facilitate personalized management of this heterogeneous, often multimorbid, population. Finally, organizational models to support patient empowerment in an integrative care pathway must be established and validated.
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Affiliation(s)
- Agnès Oude Engberink
- Desbrest Institute of Epidemiology and Public Health (IDESP), UMR UA11 INSERM-University of Montpellier, Montpellier, France
- Department of Primary Care, School of Medicine, University of Montpellier, Montpellier, France
| | - Guillaume Tessier
- Department of Primary Care, School of Medicine, University of Montpellier, Montpellier, France
| | - Ilham Kamil
- Department of Primary Care, School of Medicine, University of Montpellier, Montpellier, France
| | - Gérard Bourrel
- Desbrest Institute of Epidemiology and Public Health (IDESP), UMR UA11 INSERM-University of Montpellier, Montpellier, France
- Department of Primary Care, School of Medicine, University of Montpellier, Montpellier, France
| | - Olivier Moranne
- Desbrest Institute of Epidemiology and Public Health (IDESP), UMR UA11 INSERM-University of Montpellier, Montpellier, France.
- Nephrology-Dialysis-Apheresis Department, University Hospital of Nîmes, Place Pr Debré, Nîmes, France.
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Wallace H, Wang Q, Botha T, Hunter B, Lumsden N, Nelson C. Optimising diagnosis and management of kidney disease: an implementation trial of a clinical decision support system future health today. BMC Nephrol 2024; 25:57. [PMID: 38365641 PMCID: PMC10870544 DOI: 10.1186/s12882-024-03489-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 01/31/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Chronic kidney disease affects more than 10% of the world's population and is a non-communicable disease of global concern and priority. There is a significant implementation gap between best practice guideline recommendations and current kidney disease management. Previous research has shown the need to partner with primary care to improve education, collaboration, and kidney disease awareness. This implementation trial will explore use of an innovative clinical decision support software, Future Health Today, to improve screening, diagnosis, and management of kidney disease in primary care. The program will be supported by tertiary care outreach services. The primary aim is to test the hypothesis that the Future Health Today implementation program will improve screening, diagnosis, and management of kidney disease. Secondary aims are to evaluate primary care satisfaction and broader health service impacts. METHODS This pre-post implementation trial using an interrupted time series design will evaluate the clinical and service outcomes of Future Health Today, using a mixed methods study in twenty general practices with an estimated population size of 150,000. Deidentified patient data will be extracted from participating practices to examine the primary aims of the study. Surveys and semi-structured interviews with general practice will inform secondary hypotheses. Data linkage between primary care and tertiary care data will examine the broader health service impacts. DISCUSSION This investigator driven trial will assess the impact of Future Health Today software coupled with education and clinical outreach support. Investigators hypothesise that there will be improvement in appropriate screening, diagnosis, and management of kidney disease. This program has the potential to be scaled more broadly. TRIAL REGISTRATION Australian New Zealand Clinical Trial Registry: ACTRN12623001096640.
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Affiliation(s)
- Hannah Wallace
- Department of Medicine, Faulty of Medicine, Dentistry and Health Sciences, Western Clinical School, The University of Melbourne, Melbourne, VIC, Australia.
- Western Health Chronic Disease Alliance, Western Health, Footscray, VIC, Australia.
| | - Qiumian Wang
- Western Health Chronic Disease Alliance, Western Health, Footscray, VIC, Australia
| | - Tanita Botha
- Western Health Chronic Disease Alliance, Western Health, Footscray, VIC, Australia
- Biostatistics Units, Faculty of Health, Deakin University, Geelong, VIC, Australia
| | - Barbara Hunter
- Department of General Practice and Primary Care, Faulty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Natalie Lumsden
- Western Health Chronic Disease Alliance, Western Health, Footscray, VIC, Australia
- Department of General Practice and Primary Care, Faulty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Craig Nelson
- Department of Medicine, Faulty of Medicine, Dentistry and Health Sciences, Western Clinical School, The University of Melbourne, Melbourne, VIC, Australia
- Western Health Chronic Disease Alliance, Western Health, Footscray, VIC, Australia
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9
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Gatlin B, Miller J, Chang S. Optimizing Collaborative Care of Patients with Chronic Kidney Disease Associated with Type 2 Diabetes: An Example Practice Model at a Health Care Practice in Kentucky, United States. Diabetes Ther 2024; 15:1-11. [PMID: 37914833 PMCID: PMC10786800 DOI: 10.1007/s13300-023-01500-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 10/17/2023] [Indexed: 11/03/2023] Open
Abstract
Suboptimal multidisciplinary team collaboration is a barrier to effective health care provision for patients with chronic kidney disease (CKD) associated with type 2 diabetes mellitus (T2DM). We describe an example practice model of a clinical practice called Baptist Health Deaconess, based in Madisonville, Kentucky, USA, where a small multidisciplinary team consisting of an endocrinologist, nurse practitioner, and pharmacist (authors of this article) work collaboratively in an ambulatory care setting to provide health care to the patients they serve. Many of the patients who receive care at Baptist Health Deaconess are on a low income, have poor health literacy, and do not have a primary care physician. The presence of a pharmacist in the team allows for insurance/access investigations to assess drug choice and affordability; such aspects can be performed quickly with a pharmacist in the office.
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Affiliation(s)
- Benjamin Gatlin
- Baptist Health Deaconess Madisonville, Madisonville, KY, USA.
| | - Jamie Miller
- Baptist Health Deaconess Madisonville, Madisonville, KY, USA
| | - Sergio Chang
- Baptist Health Deaconess Madisonville, Madisonville, KY, USA
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Al-Zaman N, Alem A, Alharbi OA, Ahmed Abdullah E, Azouni DW, Hammad RK, Alhejaily RM, Albadrani M. Physicians' Knowledge, Attitudes and Barriers Regarding Chronic Kidney Disease Diagnosis and Management in Saudi Arabia. Cureus 2023; 15:e50247. [PMID: 38196437 PMCID: PMC10774705 DOI: 10.7759/cureus.50247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is defined as abnormalities of kidney structure and/or function persisting for a minimum of three months. METHODS An online cross-sectional study was conducted in the Kingdom of Saudi Arabia (KSA) between June and August 2022 to assess the knowledge, attitudes, practices, and barriers among family, internal medicine, and general physicians related to CKD screening, diagnosis, and management. RESULTS A total of 427 physicians were included in the study. The majority exhibited a strong grasp of the accurate definition of CKD (83%) and recognized common risk factors, such as diabetes (99%), drugs (95%), and hypertension (98%). Two-thirds of physicians were aware of the five stages of CKD and identified estimated glomerular filtration rate (eGFR) and creatinine clearance as the most suitable markers for kidney function. Physicians also displayed knowledge of CKD-related complications. However, a noticeable gap between knowledge and practice was evident. Only one-third of participants reported screening their patients every year, primarily using serum creatinine (92.5%) and eGFR (97%) for diagnosis, while only 16% recognized that stage 4 CKD is the appropriate time to refer patients to nephrologists. In terms of barriers, the majority of physicians reported encountering low barriers to CKD management, but general practitioners working in primary healthcare centers experienced significantly higher levels of barriers. CONCLUSION Most participants in our study possess a good level of knowledge and positive attitudes towards CKD diagnosis and management. Nevertheless, a discrepancy between knowledge and practical application, particularly in terms of over-screening and early referral, highlights the need for educational efforts to improve physician practice in KSA. These findings underscore the importance of addressing this gap to promote effective CKD management.
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Affiliation(s)
- Naweed Al-Zaman
- Internal Medicine, College of Medicine, Taibah University, Medina, SAU
| | - Alaa Alem
- Internal Medicine, College of Medicine, Taibah University, Medina, SAU
| | - Ohood A Alharbi
- Medicine, College of Medicine, Taibah University, Medina, SAU
| | | | - Duha W Azouni
- Medicine, College of Medicine, Taibah University, Medina, SAU
| | - Raghad K Hammad
- Medicine, College of Medicine, Taibah University, Medina, SAU
| | | | - Muayad Albadrani
- Family and Community Medicine, College of Medicine, Taibah University, Medina, SAU
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11
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May HP, Herges JR, Anderson BK, Hanson GJ, Kashani KB, Kattah AG, Cole KC, McCoy RG, Meade LA, Rule AD, Schreier DJ, Tinaglia AG, Barreto EF. Posthospital Multidisciplinary Care for AKI Survivors: A Feasibility Pilot. Kidney Med 2023; 5:100734. [PMID: 37964784 PMCID: PMC10641567 DOI: 10.1016/j.xkme.2023.100734] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023] Open
Abstract
Rationale & Objective Innovative models are needed to address significant gaps in kidney care follow-up for acute kidney injury (AKI) survivors. Study Design This quasi-experimental pilot study reports the feasibility of the AKI in Care Transitions (ACT) program, a multidisciplinary approach to AKI survivor care based in the primary care setting. Setting & Participants The study included consenting adults with stage 3 AKI discharged home without dialysis. Interventions The ACT intervention included predischarge education from nurses and coordinated postdischarge follow-up with a primary care provider and pharmacist within 14 days. ACT was implemented in phases (Usual Care, Education, ACT). Outcomes The primary outcome was feasibility. Secondary outcomes included process and clinical outcomes. Results In total, 46 of 110 eligible adults were enrolled. Education occurred in 18/18 and 14/15 participants in the Education and ACT groups, respectively. 30-day urine protein evaluation occurred in 15%, 28%, and 87% of the Usual Care, Education, and ACT groups, respectively (P < 0.001). Cumulative incidence of provider (primary care or nephrologist) and laboratory follow-up at 14 and 30 days was different across groups (14 days: Usual care 0%, Education 11%, ACT 73% [P < 0.01]; 30 days: 0%, 22%, and 73% [P < 0.01]). 30-day readmission rates were 23%, 44%, and 13% in the Usual Care, Education, and ACT groups, respectively (P = 0.13). Limitations Patients were not randomly assigned to treatment groups. The sample size limited the ability to detect some differences or perform multivariable analysis. Conclusions This study demonstrated the feasibility of multidisciplinary AKI survivor follow-up beginning in primary care. We observed a higher cumulative incidence of laboratory and provider follow-up in ACT participants. Trial Registration ClinicalTrials.gov (NCT04505891). Plain-Language Summary Abrupt loss of kidney function in hospitalized patients, acute kidney injury (AKI), increases the chances of long-term kidney disease and a worse health care experience for patients. One out of 3 people who experience AKI do not get the follow-up kidney care they need. We performed a pilot study to test whether a program that facilitates structured AKI follow-up in primary care called the AKI in Care Transitions (ACT) program was possible. ACT brings together the unique expertise of nurses, doctors, and pharmacists to look at the patient's kidney health plan from all angles. The study found that the ACT program was possible and led to more complete kidney care follow-up after discharge than the normal approach to care.
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Affiliation(s)
| | | | | | - Gregory J. Hanson
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Kianoush B. Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Andrea G. Kattah
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Kristin C. Cole
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
| | - Rozalina G. McCoy
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, MN
- Division of Health Care Delivery Research, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Laurie A. Meade
- Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, MN
| | - Andrew D. Rule
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | | | | | - ACT Study Group
- Department of Pharmacy, Mayo Clinic, Rochester, MN
- Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, MN
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, MN
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
- Division of Health Care Delivery Research, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
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12
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Xu Y, Evans M, Mazhar F, Ärnlöv J, Cockburn E, Barany P, Carrero JJ. Poor recognition and undertreatment of anemia in patients with chronic kidney disease managed in primary care. J Intern Med 2023; 294:628-639. [PMID: 37463872 DOI: 10.1111/joim.13702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Anemia is a common complication of chronic kidney disease (CKD), but limited awareness and treatment options may hinder its management among CKD patients followed in primary care. METHODS We evaluated adults with CKD stages 3-5 attending primary care in Stockholm, Sweden, 2012-2018. We assessed the incidence of anemia, clinical reactions, and association with subsequent major adverse cardiovascular events (MACE) and death. RESULTS We identified 45,637 patients with CKD stages 3-5 free from anemia (mean age 78 years; 64% females; 79% CKD stage 3b). During a median follow-up of 2.4 years, 26% of patients developed anemia, and 10.4% developed severe anemia (hemoglobin <10 g/dL). Within 6 months from the anemia event, iron tests were infrequent; ferritin and transferrin saturation were tested in 27% and 11% of anemia cases, respectively, and 49% and 24% of severe anemia cases. Few patients were recognized with a clinical diagnosis (15% of anemia cases; 68% of severe anemias). Only 19% of patients with anemia received treatment, primarily iron (10%) and blood transfusions (7%); erythropoietin-stimulating agent use was anecdotal (∼1%). Treatment rates for severe anemia were higher, but 43% of patients still failed to receive treatment. Developing anemia was associated with a higher risk of MACE and death. CONCLUSION Anemia was common and associated with adverse outcomes among patients with CKD stages 3-5 managed in primary care. Iron stores were infrequently tested, and a large proportion of patients with anemia remained untreated/under-recognized.
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Affiliation(s)
- Yang Xu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Marie Evans
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Division of Nephrology, Karolinska University Hospital, Solna, Sweden
| | - Faizan Mazhar
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Johan Ärnlöv
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | | | - Peter Barany
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Division of Nephrology, Karolinska University Hospital, Solna, Sweden
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Division of Nephrology, Department of Clinical Sciences, Danderyd Hospital, Danderyd, Sweden
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13
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Miller A, Brown L, Tamu C, Cairns A. Cape York Kidney Care: service description and baseline characteristics of a client-centred multidisciplinary specialist kidney health service in remote Australia. BMC Health Serv Res 2023; 23:907. [PMID: 37620879 PMCID: PMC10463956 DOI: 10.1186/s12913-023-09887-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 08/08/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Chronic Kidney disease (CKD) is over-represented amongst First Nation people with more than triple the rate of CKD in those aged 15 years and over. The impact of colonisation, including harmful experiences of health practices and research, has contributed to these health inequities. Cape York Kidney Care (CYKC) has been created as an unique service which provides specialist care that aims to centre the client within a multidisciplinary team that is integrated within the primary care setting of the remote health clinics in six communities in western Cape York, Australia. This research aims to describe the Cape York Kidney Care service delivery model, and baseline service data, including aggregated client health measures. METHODS The model of care is described in detail. Review of the first 12 months of service provision has been undertaken with client demographic and clinical profile baseline data collected including kidney health measures. Participants are adults (> 18 years if age) with CKD grades 1-5. This data has been de-identified and aggregated. RESULTS CYKC reviewed 204 individuals, with 182 not previously been reviewed by specialist kidney health services. Three quarters of clients identified as Aboriginal. The average age was 55 with a high level of comorbidity, with majority having a history of hypertension and Type 2 diabetes (average Hba1c 8.2%). Just under one third had cardiovascular disease. A large proportion of people had either Grade 2 CKD (32%) or Grade 3 CKD (~ 30%), and over half had severely increased albuminuria (A3), with Type 2 diabetes being the predominant presumed cause of CKD. Most clients did not meet evidence-based targets for diabetes, blood pressure or lipids and half were self-reported smokers. The proportion of clients reviewed represents 6.2% of the adult population in the participating First Nation communities. CONCLUSION The CYKC model was able to target those clients at high risk of progression and increase the number of people with chronic kidney disease reviewed by specialist kidney services within community. Baseline data demonstrated a high burden of chronic disease that subsequently will increase risk of CKD progression and cardiovascular disease. People were seen to have more severe disease at younger ages, with a substantial number demonstrating risk factors for rapid progression of kidney disease including poorly controlled Type 2 diabetes and severely increased albuminuria. Further evaluation concerning implementation challenges, consumer and community satisfaction, and health outcomes is required.
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Affiliation(s)
- Andrea Miller
- Torres and Cape Hospital and Health Service, PO Box 341, Weipa, QLD, Australia.
- Murtupuni Centre for Rural and Remote Health, & Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, Queensland, Australia.
| | - Leanne Brown
- Torres and Cape Hospital and Health Service, PO Box 341, Weipa, QLD, Australia
- Murtupuni Centre for Rural and Remote Health, & Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, Queensland, Australia
| | - Clara Tamu
- Torres and Cape Hospital and Health Service, Ngurapai/Horn Island Primary Health Care Centre, Horn Island, Queensland, Australia
| | - Alice Cairns
- Murtupuni Centre for Rural and Remote Health, & Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, Queensland, Australia
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14
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Ng JH, Halinski C, Nair D, Diefenbach MA. Impact of COVID-19 on Disease Self-management Among Patients With Advanced CKD: A Qualitative Study. Kidney Med 2023; 5:100689. [PMID: 37360218 PMCID: PMC10268812 DOI: 10.1016/j.xkme.2023.100689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 04/30/2023] [Indexed: 06/28/2023] Open
Abstract
Rationale & Objective Patients with advanced chronic kidney disease (CKD) and their care partners experienced decreased access to care, and worse physical and emotional health during the Coronavirus Disease-19 (COVID-19) pandemic. Few studies have explored how COVID-19-related challenges affected disease self-management among those with advanced chronic kidney disease (CKD) and their care partners. Leventhal's self-regulation model offers a comprehensive framework for understanding disease self-management through the interplay of cognitive beliefs, emotional reactions and social influences. The study aims to examine the impact of COVID-19 on self-management activities among patients with CKD and care partners. Study Design Qualitative study. Setting & Participants Adults with advanced CKD, including dialysis and transplant recipients, and their carepartners. Analytical Approach Thematic Analysis. Results Among 42 participants, 12 had stage 4 CKD, 5 had stage 5 CKD, 6 were receiving in-center hemodialysis, 5 had a kidney transplant, and 14 were care partners. We identified 4 patient-related themes with corresponding subthemes related to the impact of COVID-19 on self-management: 1) cognitive understanding that COVID-19 is an additional health threat to existing kidney disease, 2) heightened anxiety and vulnerability driven by perceived risk, 3) coping with isolation through virtual interactions with healthcare services and social circles, 4) increased protective behaviors to maximize survival. Three care partner-related themes emerged: 1) hypervigilance in family care and protection, 2) interaction with health system and adaptations to self-management, and 3) increased intensity in caregiving role to facilitate patient self-management. Limitations The qualitative study design limits the ability to generate generalizable data. Grouping patients with Stage 3 and 4 CKD, in-center hemodialysis, and kidney transplants together limited our ability to examine self-management challenges specific to each treatment requirement. Conclusions When faced with the COVID-19 pandemic, patients with CKD and their care partners experienced heightened vulnerability and thus increased cautionary activities to maximize survival. Our study provides the groundwork for future interventions to help patients and care partners live with kidney disease during future crises.
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Affiliation(s)
- Jia H. Ng
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
- Division of Kidney Diseases and Hypertension, Northwell Health
| | - Candice Halinski
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
- Division of Kidney Diseases and Hypertension, Northwell Health
| | - Devika Nair
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Michael A. Diefenbach
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
- Institute of Health System Science, Feinstein Institutes for Medical Research
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15
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Duong H, Tesfaye W, Van C, Sud K, Truong M, Krass I, Castelino RL. Sick day management in people with chronic kidney disease: a scoping review. J Nephrol 2023; 36:1293-1306. [PMID: 36327038 PMCID: PMC10333414 DOI: 10.1007/s40620-022-01497-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Use of certain medications during an acute illness may put patients at an increased risk of acute kidney injury (AKI). Patients with chronic kidney disease (CKD) are at higher risk of developing superimposed AKI. The aim of this scoping review is to collate and characterise existing evidence on sick day management considerations and practices during acute illness in people with CKD. METHODS We searched Embase, CINAHL, MEDLINE, International Pharmaceutical Abstract, Scopus, Google Scholar and grey literature sources. We followed the methodological framework for scoping reviews, while information was extracted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. Findings are presented thematically. RESULTS Ten studies and seven guidelines met the inclusion criteria. Studies were targeted at patients, general practitioners, pharmacists, and nurses. The major themes identified included development and feasibility testing of a sick day management protocol, current practice of temporary medication discontinuation, and outcomes. Most guidelines provided recommendations for sick day management largely based on expert consensus. A digital intervention was deemed highly acceptable and easy to use, whereas patient handouts were more effective when provided along with dialogue with a health professional. While there is little evidence on the impact of sick day protocols on outcomes, a single randomised trial reported no significant association between sick day protocols and change in kidney function, AKI incidents or risk of hospitalisation. CONCLUSION The nascent literature on sick day management in patients with CKD revealed the limited available evidence to provide guidance on implementation and on outcomes. Future research needs to clarify sick day recommendations and assess their impact on clinical outcomes including prevention of superimposed AKI or hospitalisations, as well as to address barriers to implementation.
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Affiliation(s)
- Henna Duong
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Wubshet Tesfaye
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Sydney Pharmacy School, The University of Sydney, A15, Science Rd , Camperdown, NSW 2006 Australia
| | - Connie Van
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Kamal Sud
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Renal Medicine, Nepean Hospital, Nepean and Blue Mountains Local Health District, Katoomba, Australia
| | - Mimi Truong
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Ines Krass
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Ronald L Castelino
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Pharmacy Department, Blacktown Hospital, WSLHD, Blacktown, Australia
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16
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Wang T, Tan JYB, Liu XL, Zhao I. Barriers and enablers to implementing clinical practice guidelines in primary care: an overview of systematic reviews. BMJ Open 2023; 13:e062158. [PMID: 36609329 PMCID: PMC9827241 DOI: 10.1136/bmjopen-2022-062158] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES To identify the barriers and enablers to implementing clinical practice guidelines (CPGs) recommendations in primary care and to provide recommendations that could facilitate the uptake of CPGs recommendations. DESIGN An overview of systematic reviews. DATA SOURCES Nine electronic databases (PubMed, Cochrane Library, CINAHL, MEDLINE, PsycINFO, Web of Science, Journals @Ovid Full Text, EMBase, JBI) and three online data sources for guidelines (Turning Research Into Practice, the National Guideline Clearinghouse and the National Institute for Health and Care Excellence) were searched until May 2021. ELIGIBILITY CRITERIA Systematic reviews, meta-analyses or other types of systematic synthesis of quantitative, qualitative or mixed-methods studies on the topic of barriers and/or enablers for CPGs implementation in primary care were included. DATA EXTRACTION AND SYNTHESIS Two authors independently screened the studies and extracted the data using a predesigned data extraction form. The methodological quality of the included studies was appraised by using the JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses. Content analysis was used to synthesise the data. RESULTS Twelve systematic reviews were included. The methodological quality of the included reviews was generally robust. Six categories of barriers and enablers were identified, which include (1) political, social and culture factors, (2) institutional environment and resources factors, (3) guideline itself related factors, (4) healthcare provider-related factors, (5) patient-related factors and (6) behavioural regulation-related factors. The most commonly reported barriers within the above-mentioned categories were suboptimal healthcare networks and interprofessional communication pathways, time constraints, poor applicability of CPGs in real-world practice, lack of knowledge and skills, poor motivations and adherence, and inadequate reinforcement (eg, remuneration). Presence of technical support ('institutional environment and resources factors'), and timely education and training for both primary care providers (PCPs) ('healthcare provider-related factors') and patients ('patient-related factors') were the frequently reported enablers. CONCLUSION Policy-driven strategies should be developed to motivate different levels of implementation activities, which include optimising resources allocations, promoting integrated care models, establishing well-coordinated multidisciplinary networks, increasing technical support, encouraging PCPs and patients' engagement in guideline development, standardising the reporting of guidelines, increasing education and training, and stimulating PCPs and patients' motivations. All the activities should be conducted by fully considering the social, cultural and community contexts to ensure the success and sustainability of CPGs implementation.
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Affiliation(s)
- Tao Wang
- Faculty of Health, Charles Darwin University, Brisbane, Queensland, Australia
| | | | - Xian-Liang Liu
- Faculty of Health, Charles Darwin University, Brisbane, Queensland, Australia
| | - Isabella Zhao
- Faculty of Health, Charles Darwin University, Brisbane, Queensland, Australia
- Cancer and Palliative Care Outcomes Centre, Queensland University of Technology, Brisbane, Queensland, Australia
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17
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Quality, safety, and implementation science in acute kidney care. Curr Opin Crit Care 2022; 28:613-621. [PMID: 36226720 DOI: 10.1097/mcc.0000000000000999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW Quality and safety are important themes in acute kidney care (AKC). There have been many recent initiatives highlighting these aspects. However, for these to become part of clinical practice, a rigorous implementation science methodology must be followed. This review will present these practices and will highlight recent initiatives in acute kidney injury (AKI), kidney replacement therapy (KRT) and recovery from AKI. RECENT FINDINGS The 22nd Acute Disease Quality Initiative (ADQI) focused on achieving a framework for improving AKI care. This has led to various quality improvement (QI) initiatives that have been implemented following a robust implementation science methodology. In AKI, QI initiatives have been focused on implementing care bundles and early detection systems for patients at risk or with AKI. KRT initiatives have focused on measuring and reporting key performance indicators (KPIs), and providing targeted feedback and education to improve delivery of KRT. Finally, it has been recognized that post-AKI care is vitally important, and ongoing work has been focused on implementing pathways to ensure continuing kidney-focused care. SUMMARY Quality and safety continue to be important focuses in AKC. Although recent work have focused on initiatives to improve these themes, additional work is necessary to further develop these items as we strive to improve the care to patients with AKI.
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18
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Lightfoot CJ, Wilkinson TJ, Hadjiconstantinou M, Graham-Brown M, Barratt J, Brough C, Burton JO, Hainsworth J, Johnson V, Martinez M, Nixon AC, Pursey V, Schreder S, Vadaszy N, Wilde L, Willingham F, Young HML, Yates T, Davies MJ, Smith AC. The Codevelopment of "My Kidneys & Me": A Digital Self-management Program for People With Chronic Kidney Disease. J Med Internet Res 2022; 24:e39657. [PMID: 36374538 PMCID: PMC9706383 DOI: 10.2196/39657] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/05/2022] [Accepted: 08/11/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Health care self-management is important for people living with nondialysis chronic kidney disease (CKD). However, the few available resources are of variable quality. OBJECTIVE This work describes the systematic codevelopment of "My Kidneys & Me" (MK&M), a theory-driven and evidence-based digital self-management resource for people with nondialysis CKD, guided by an established process used for the successful development of the diabetes education program MyDESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed, DESMOND). METHODS A multidisciplinary steering group comprising kidney health care professionals and researchers and specialists in the development of complex interventions and digital health provided expertise in the clinical and psychosocial aspects of CKD, self-management, digital health, and behavior change. A patient and public involvement group helped identify the needs and priorities of MK&M and co-design the resource. MK&M was developed in 2 sequential phases. Phase 1 involved the codevelopment process of the MK&M resource (content and materials), using Intervention Mapping (IM) as a framework. The first 4 IM steps guided the development process: needs assessment was conducted to describe the context of the intervention; intervention outcomes, performance objectives, and behavioral determinants were identified; theory- and evidence-based change methods and practical strategies to deliver change methods were selected; and program components were developed and refined. Phase 2 involved the adoption and adaptation of the existing MyDESMOND digital platform to suit the MK&M resource. RESULTS The needs assessment identified that individuals with CKD have multiple differing needs and that delivering a self-management program digitally would enable accessible, tailored, and interactive information and support. The intended outcomes of MK&M were to improve and maintain effective self-management behaviors, including physical activity and lifestyle, improve knowledge, promote self-care skills, increase self-efficacy, and enhance well-being. This was achieved through the provision of content and materials designed to increase CKD knowledge and patient activation, reduce health risks, manage symptoms, and improve physical function. Theories and behavior change techniques selected include Self-Management Framework, Capability, Opportunity, Motivation Behavior model components of Behaviour Change Wheel and taxonomy of behavior change techniques, Health Action Process Approach Model, Common Sense Model, and Social Cognitive Theory. The program components developed comprised educational and behavior change sessions, health trackers (eg, monitoring blood pressure, symptoms, and exercise), goal-setting features, and forums for social support. The MyDESMOND digital platform represented an ideal existing platform to host MK&M; thus, the MyDESMOND interface and features were adopted and adapted for MK&M. CONCLUSIONS Applying the IM framework enabled the systematic application of theory, empirical evidence, and practical perspectives in the codevelopment of MK&M content and materials. Adopting and adapting a preexisting platform provided a cost- and time-efficient approach for developing our digital intervention. In the next stage of work, the efficacy of MK&M in increasing patient activation will be tested in a randomized controlled trial.
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Affiliation(s)
- Courtney J Lightfoot
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester, Leicester, United Kingdom
- Leicester Biomedical Research Centre, Leicester, United Kingdom
| | - Thomas J Wilkinson
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester, Leicester, United Kingdom
- National Institute for Health Research Applied Research Collaboration East Midlands, Leicester Diabetes Centre, Leicester, United Kingdom
| | | | - Matthew Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Department of Renal Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Department of Renal Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Christopher Brough
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - James O Burton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Department of Renal Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom
| | - Jenny Hainsworth
- Department of Medical Psychology, Leicestershire Partnership NHS Trust, Leicester, United Kingdom
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Vicki Johnson
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Maria Martinez
- Renal and Transplant Unit, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Andrew C Nixon
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Victoria Pursey
- Department of Renal Medicine, York Teaching Hospital NHS Foundation Trust, York, United Kingdom
| | - Sally Schreder
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Noemi Vadaszy
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Lucina Wilde
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Fiona Willingham
- Nutrition and Dietetics Team, School of Sport and Health Sciences, University of Central Lancashire, Preston, United Kingdom
- Nutrition and Dietetic Department, East Lancashire Hospitals NHS Trust, Blackburn, United Kingdom
| | - Hannah M L Young
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Thomas Yates
- Leicester Biomedical Research Centre, Leicester, United Kingdom
- Diabetes Research Centre, College of Life Sciences, University of Leicester, Leicester, United Kingdom
| | - Melanie J Davies
- Leicester Biomedical Research Centre, Leicester, United Kingdom
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
| | - Alice C Smith
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester, Leicester, United Kingdom
- Leicester Biomedical Research Centre, Leicester, United Kingdom
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Rivera E, Clark-Cutaia MN, Schrauben SJ, Townsend RR, Lash JP, Hannan M, Jaar BG, Rincon-Choles H, Kansal S, He J, Chen J, Hirschman KB. Treatment Adherence in CKD and Support From Health care Providers: A Qualitative Study. Kidney Med 2022; 4:100545. [PMID: 36339664 PMCID: PMC9630784 DOI: 10.1016/j.xkme.2022.100545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Rationale & Objective Adherence to recommended medical treatment is critical in chronic kidney disease (CKD) to prevent complications and progression to kidney failure. Overall adherence to treatment is low in CKD, and as few as 40% of patients with kidney failure receive any documented CKD-related care. The purpose of this study was to explore the experiences of patients with CKD and their adherence to CKD treatment plans, and the role their health care providers played in supporting their adherence. Study Design One-on-one interviews were conducted in 2019-2020 using a semi-structured interview guide. Participants described experiences with adherence to treatment plans and what they did when experiencing difficulty. Setting & Participants Participants were recruited from the Chronic Renal Insufficiency Cohort (CRIC) study. All CRIC participants were older than 21 years with CKD stages 2-4; this sample consisted of participants from the University of Pennsylvania CRIC site. Analytical Approach Interviews were recorded, transcribed, and coded using conventional content analysis. Data were organized into themes using NVivo 12. Results The sample (n = 32) had a mean age of 67 years, 53% were women, 59% were non-White, with a mean estimated glomerular filtration rate of 56.6 mL/min/1.73 m2. From analysis of factors relevant to treatment planning and adherence, following 4 major themes emerged: patient factors (multiple chronic conditions, motivation, outlook), provider factors (attentiveness, availability/accessibility, communication), treatment planning factors (lack of plan, proactive research, provider-focused treatment goals, and shared decision making), and treatment plan responses (disagreeing with treatment, perceived capability deficit, lack of information, and positive feedback). Limitations The sample was drawn from the CRIC study, which may not be representative of the general population with CKD. Conclusions These themes align with Behavioral Learning Theory, which includes concepts of internal antecedents (patient factors), external antecedents (provider factors), behavior (treatment planning factors), and consequences (treatment plan responses). In particular, the treatment plan responses point to innovative potential intervention approaches to support treatment adherence in CKD.
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Affiliation(s)
- Eleanor Rivera
- Department of Population Health Nursing Science, College of Nursing, University of Illinois Chicago, Chicago, IL
| | | | - Sarah J. Schrauben
- Division of Renal Electrolyte and Hypertension, School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Raymond R. Townsend
- Division of Renal Electrolyte and Hypertension, School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - James P. Lash
- Division of Nephrology, College of Medicine, University of Illinois Chicago, Chicago, IL
| | - Mary Hannan
- Department of Biobehavioral Nursing Science, College of Nursing, University of Illinois Chicago, Chicago, IL
| | - Bernard G. Jaar
- Division of Nephrology, School of Medicine, Johns Hopkins University, Baltimore, MD
| | | | - Sheru Kansal
- Division of Nephrology and Hypertension, University Hospital Cleveland Medical Center, University Hospitals, Cleveland, OH
| | - Jiang He
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA
| | - Jing Chen
- Department of Medicine, School of Medicine, Tulane University, New Orleans, LA
| | - Karen B. Hirschman
- Department of Biobehavioral Health Sciences, School of Nursing, University of Pennsylvania, Philadelphia, PA
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20
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Comparison of the 2013 and 2019 Nationwide Surveys on the Management of Chronic Kidney Disease by General Practitioners in Japan. J Clin Med 2022; 11:jcm11164779. [PMID: 36013020 PMCID: PMC9410076 DOI: 10.3390/jcm11164779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 11/17/2022] Open
Abstract
In 2019, the Japan Physicians Association conducted a second nationwide survey on the management of chronic kidney disease (CKD) among the Japanese general practitioners (GPs). We aimed to clarify the changes in the state of CKD medical care by GPs since the 2013 survey. The 2013 and 2019 surveys included 2214 and 601 GPs, respectively, who voluntarily participated. The two surveys were compared, using propensity score matching to balance the background of the responded GPs. For the medical care of CKD, the frequency of urine or blood examination, use of estimated glomerular filtration rate (eGFR) value for CKD management, and continuous use of renin-angiotensin system inhibitors for their reno-protective effects were significantly higher in 2019 than in 2013 (all: p < 0.001). The medical cooperation in CKD management, the utilization of the clinical path for CKD management and the measurement of the eGFR during the medical health checkup were significantly increased in 2019, compared to those in 2013. More GPs felt dissatisfied with the components of CKD treatment by nephrologists (p < 0.001). The two surveys confirmed improvements in the level of medical care for CKD and a strengthening in cooperation. However, the dissatisfaction with the consultation with nephrologists did not necessarily improve.
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21
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Evaluation of the clinical utility of the PromarkerD in-vitro test in predicting diabetic kidney disease and rapid renal decline through a conjoint analysis. PLoS One 2022; 17:e0271740. [PMID: 35913946 PMCID: PMC9342737 DOI: 10.1371/journal.pone.0271740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 07/06/2022] [Indexed: 11/19/2022] Open
Abstract
Background Early identification of patients at risk of developing diabetic kidney disease or rapid renal decline is imperative for appropriate patient management, but traditional methods of predicting renal decline are limited. Objective This study evaluated the impact of PromarkerD, a biomarker-based blood test predicting the risk of diabetic kidney disease (DKD) and rapid renal decline. Methods Conjoint analysis clarified the importance of PromarkerD and other patient attributes to physician decisions for type 2 diabetes patients. Forty-two patient profiles were generated, with varying levels of albuminuria, estimated glomerular filtration rate (eGFR), blood pressure, hemoglobin A1c (HbA1c), age, and PromarkerD result. A web-based survey asked each physician to make monitoring/treatment decisions about eight randomly selected profiles. Data were analyzed using multivariable logit models. Results Two hundred three primary care physicians and 197 endocrinologists completed the survey. PromarkerD result was most important for increasing the frequency of risk factor monitoring. PromarkerD was second to HbA1c in importance for deciding to prescribe sodium/glucose cotransporter-2 inhibitors (SGLT2s) with a DKD indication, second to blood pressure for increasing the dose of lisinopril, and second to eGFR for replacing ibuprofen with a non-nephrotoxic medication. Compared with no PromarkerD results, a high-risk PromarkerD result was associated with significantly higher odds of increasing monitoring frequency (odds ratio [OR]: 2.56, 95% confidence interval: 1.90–3.45), prescribing SGLT2s (OR: 1.98 [1.56–2.52]), increasing lisinopril dose (OR: 1.48 [1.17–1.87]), and replacing ibuprofen (OR: 1.78 [1.32–2.40]). A low-risk PromarkerD result was associated with significantly lower odds of increasing monitoring frequency (OR: 0.48 [0.37–0.64]), prescribing SGLT2s (OR: 0.70 [0.56–0.88]), and replacing ibuprofen (OR: 0.75 [0.57–0.99]). Conclusion PromarkerD could increase adoption of renoprotective interventions in patients at high risk for renal decline and lower the likelihood of aggressive treatment in those at low risk. Further studies are needed to assess patient outcomes with PromarkerD in real-world practice.
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22
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May HP, Krauter AK, Finnie DM, McCoy RG, Kashani KB, Griffin JM, Barreto EF. Optimising transitions of care for acute kidney injury survivors: protocol for a mixed-methods study of nephrologist and primary care provider recommendations. BMJ Open 2022; 12:e058613. [PMID: 35732395 PMCID: PMC9226954 DOI: 10.1136/bmjopen-2021-058613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Acute kidney injury (AKI) affects nearly 20% of all hospitalised patients and is associated with poor outcomes. Long-term complications can be partially attributed to gaps in kidney-focused care and education during transitions. Building capacity across the healthcare spectrum by engaging a broad network of multidisciplinary providers to facilitate optimal follow-up care represents an important mechanism to address this existing care gap. Key participants include nephrologists and primary care providers and in-depth study of each specialty's approach to post-AKI care is essential to optimise care processes and healthcare delivery for AKI survivors. METHODS AND ANALYSIS This explanatory sequential mixed-methods study uses survey and interview methodology to assess nephrologist and primary care provider recommendations for post-AKI care, including KAMPS (kidney function assessment, awareness and education, medication review, blood pressure monitoring and sick day education) elements of follow-up, the role of multispecialty collaboration, and views on care process-specific and patient-specific factors influencing healthcare delivery. Nephrologists and primary care providers will be surveyed to assess recommendations and clinical decision-making in the context of post-AKI care. Descriptive statistics and the Pearson's χ2 or Fisher's exact test will be used to compare results between groups. This will be followed by semistructured interviews to gather rich, qualitative data that explains and/or connects results from the quantitative survey. Both deductive analysis and inductive analysis will occur to identify and compare themes. ETHICS AND DISSEMINATION This study has been reviewed and deemed exempt by the Institutional Review Board at Mayo Clinic (IRB 20-0 08 793). The study was deemed exempt due to the sole use of survey and interview methodology. Results will be disseminated in presentations and manuscript form through peer-reviewed publication.
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Affiliation(s)
| | | | - Dawn M Finnie
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | | | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Joan M Griffin
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
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23
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Ramakrishnan C, Tan NC, Yoon S, Hwang SJ, Foo MWY, Paulpandi M, Gun SY, Lee JY, Chang ZY, Jafar TH. Healthcare professionals' perspectives on facilitators of and barriers to CKD management in primary care: a qualitative study in Singapore clinics. BMC Health Serv Res 2022; 22:560. [PMID: 35473928 PMCID: PMC9044787 DOI: 10.1186/s12913-022-07949-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 04/11/2022] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION The burden of chronic kidney disease (CKD) is rising globally including in Singapore. Primary care is the first point of contact for most patients with early stages of CKD. However, several barriers to optimal CKD management exist. Knowing healthcare professionals' (HCPs) perspectives is important to understand how best to strengthen CKD services in the primary care setting. Integrating a theory-based framework, we explored HCPs' perspectives on the facilitators of and barriers to CKD management in primary care clinics in Singapore. METHODS In-depth interviews were conducted on a purposive sample of 20 HCPs including 13 physicians, 2 nurses and 1 pharmacist from three public primary care polyclinics, and 4 nephrologists from one referral hospital. Interviews were audio recorded, transcribed verbatim and thematically analyzed underpinned by the Theoretical Domains Framework (TDF) version 2. RESULTS Numerous facilitators of and barriers to CKD management identified. HCPs perceived insufficient attention is given to CKD in primary care and highlighted several barriers including knowledge and practice gaps, ineffective CKD diagnosis disclosure, limitations in decision-making for nephrology referrals, consultation time, suboptimal care coordination, and lack of CKD awareness and self-management skills among patients. Nevertheless, intensive CKD training of primary care physicians, structured CKD-care pathways, multidisciplinary team-based care, and prioritizing nephrology referrals with risk-based assessment were key facilitators. Participants underscored the importance of improving awareness and self-management skills among patients. Primary care providers expressed willingness to manage early-stage CKD as a collaborative care model with nephrologists. Our findings provide valuable insights to design targeted interventions to enhance CKD management in primary care in Singapore that may be relevant to other countries. CONCLUSIONS The are several roadblocks to improving CKD management in primary care settings warranting urgent attention. Foremost, CKD deserves greater priority from HCPs and health planners. Multipronged approaches should urgently address gaps in care coordination, patient-physician communication, and knowledge. Strategies could focus on intensive CKD-oriented training for primary care physicians and building novel team-based care models integrating structured CKD management, risk-based nephrology referrals coupled with education and motivational counseling for patients. Such concerted efforts are likely to improve outcomes of patients with CKD and reduce the ESKD burden.
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Affiliation(s)
- Chandrika Ramakrishnan
- grid.428397.30000 0004 0385 0924Duke-NUS Medical School, Program in Health Services & Systems Research, 8 College Road Singapore 169857, Singapore, Singapore
| | - Ngiap Chuan Tan
- grid.490507.f0000 0004 0620 9761Department of Research, SingHealth Polyclinics, Singapore, Singapore ,grid.490507.f0000 0004 0620 9761General Practice, SingHealth Polyclinics, Singapore, Singapore
| | - Sungwon Yoon
- grid.428397.30000 0004 0385 0924Duke-NUS Medical School, Program in Health Services & Systems Research, 8 College Road Singapore 169857, Singapore, Singapore
| | - Sun Joon Hwang
- grid.428397.30000 0004 0385 0924Duke-NUS Medical School, Program in Health Services & Systems Research, 8 College Road Singapore 169857, Singapore, Singapore
| | - Marjorie Wai Yin Foo
- grid.490507.f0000 0004 0620 9761Department of Research, SingHealth Polyclinics, Singapore, Singapore ,grid.163555.10000 0000 9486 5048Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Muthulakshmi Paulpandi
- grid.490507.f0000 0004 0620 9761Department of Research, SingHealth Polyclinics, Singapore, Singapore
| | - Shi Ying Gun
- grid.490507.f0000 0004 0620 9761General Practice, SingHealth Polyclinics, Singapore, Singapore
| | - Jia Ying Lee
- grid.490507.f0000 0004 0620 9761General Practice, SingHealth Polyclinics, Singapore, Singapore
| | - Zi Ying Chang
- grid.490507.f0000 0004 0620 9761General Practice, SingHealth Polyclinics, Singapore, Singapore
| | - Tazeen H. Jafar
- grid.428397.30000 0004 0385 0924Duke-NUS Medical School, Program in Health Services & Systems Research, 8 College Road Singapore 169857, Singapore, Singapore ,grid.163555.10000 0000 9486 5048Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
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Referring patients with stable moderate to advanced chronic kidney disease back to primary care: a feasibility study. BJGP Open 2022; 6:BJGPO.2021.0177. [PMID: 35135814 PMCID: PMC9447312 DOI: 10.3399/bjgpo.2021.0177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/15/2021] [Indexed: 11/05/2022] Open
Abstract
Background Care for patients with chronic kidney disease (CKD) necessitates tailored pathways between primary and secondary care. It is unknown if back referring patients with CKD is safe and effective. Aim To study the feasibility of discharging patients with stable moderate-to-advanced CKD from secondary to primary care, and to evaluate quality of care (QoC) and patients’ and GPs‘ experiences. Design & setting A monocentre prospective mixed-method study in the Netherlands. Method Patients were included who met pre-determined back-referral (BR) criteria. Patients were discharged with personalised information guides and transfer letters. GPs had the option of consulting a nephrologist by telenephrology. Renal outcomes, QoC, and experiences were collected after 1 year. Results Eighteen patients were included. The mean age was 73 years; the mean estimated glomerular filtration rate (eGFR) was 33.2 ml/min/1.73 m2 at baseline. After 1 year, four patients had received either no or incomplete monitoring, and one patients’ blood pressure was too high. The remaining 13 had stable eGFR, proteinuria, and metabolic parameters. Patients were satisfied with information provision and treatment by GPs but expected more frequent monitoring. In one-third of cases, monitoring frequency was decreased by GPs for several reasons. GPs believed they had sufficient knowledge to treat patients with CKD, but indicated they needed support besides a transfer letter. Conclusion BR seems safe and feasible for patients with stable moderate-to-advanced CKD who meet specific criteria. Patients have good renal outcomes after 1 year and are satisfied with treatment. GP QoC can be improved, particularly completeness and monitoring frequency.
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Chu L, Bhogal SK, Lin P, Steele A, Fuller M, Ciaccia A, Abitbol A. AWAREness of diagnosis and treatment of Chronic Kidney Disease in adults with Type 2 Diabetes (AWARE-CKD in T2D). Can J Diabetes 2022; 46:464-472. [DOI: 10.1016/j.jcjd.2022.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 01/19/2022] [Accepted: 01/25/2022] [Indexed: 11/27/2022]
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Fildes K, Stefoska‐Needham A, Atkinson J, Lambert K, Lee A, Pugh D, Smyth M, Turner R, Wallace S, Nealon J. Optimising health care for people living with chronic kidney disease: Health‐professional perspectives. J Ren Care 2022; 48:168-176. [DOI: 10.1111/jorc.12409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/29/2021] [Accepted: 12/05/2021] [Indexed: 12/25/2022]
Affiliation(s)
- Karen Fildes
- School of Medicine, Faculty of Science Medicine and Health, Health Impact Research Cluster University of Wollongong Wollongong New South Wales Australia
| | - Anita Stefoska‐Needham
- School of Medicine, Faculty of Science Medicine and Health, Health Impact Research Cluster University of Wollongong Wollongong New South Wales Australia
| | - Josie Atkinson
- School of Medicine, Faculty of Science Medicine and Health, Health Impact Research Cluster University of Wollongong Wollongong New South Wales Australia
| | - Kelly Lambert
- School of Medicine, Faculty of Science Medicine and Health, Health Impact Research Cluster University of Wollongong Wollongong New South Wales Australia
| | - Anna Lee
- Nurse Practitioner Renal Service, Illawarra Shoalhaven Local Health District Warrawong New South Wales Australia
| | - Debbie Pugh
- Renal Unit, Illawarra Shoalhaven Local Health District Warrawong New South Wales Australia
| | - Mikki Smyth
- Renal Unit, Illawarra Shoalhaven Local Health District Warrawong New South Wales Australia
| | - Rebecca Turner
- School of Medicine, Faculty of Science Medicine and Health University of Wollongong Wollongong New South Wales Australia
| | - Samantha Wallace
- School of Medicine, Faculty of Science Medicine and Health University of Wollongong Wollongong New South Wales Australia
| | - Jessica Nealon
- School of Medicine, Faculty of Science Medicine and Health, Health Impact Research Cluster University of Wollongong Wollongong New South Wales Australia
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Torreggiani M, Chatrenet A, Fois A, Coindre JP, Crochette R, Sigogne M, Wacrenier S, Seret G, Mazé B, Lecointre L, Breuer C, Fessi H, Piccoli GB. Unmet needs for CKD care: from the general population to the CKD clinics-how many patients are we missing? Clin Kidney J 2021; 14:2246-2254. [PMID: 34804521 PMCID: PMC8598117 DOI: 10.1093/ckj/sfab055] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 02/15/2021] [Indexed: 12/16/2022] Open
Abstract
Introduction Prevalence of chronic kidney disease (CKD) varies around the world. Little is known about the discrepancy between the general population's needs and nephrology care offered. We aimed to contribute to filling this gap and propose a means to infer the number of patients needing follow-up. Methods All patients undergoing at least one nephrology consultation in 2019 were enrolled. We used the ratio between CKD Stages 3 and 4 reported in the literature, and considered that only 25–50% of CKD Stage 3 patients have progressive CKD, to hypothesize different scenarios to estimate the number of CKD Stage 3 patients still needing nephrology follow-up. Results The 1992 CKD patients were followed-up in our centre (56.93% males; age 66.71 ± 18.32 years; 16.82% Stage 1; 14.66% Stage 2; 39.46% Stage 3; 19.88% Stage 4; 7.68% Stage 5). The ratio between Stages 3 and 4 in population studies ranged from 7.72 to 51.29, being 1.98 in our centre. Hypothesizing that we followed-up 100, 70 or 50% of CKD Stage 4 patients, 528–2506 CKD Stage 3 patients in our area would need nephrology follow-up [1885–8946 per million population (p.m.p.)]. Three to 17 additional nephrologists p.m.p. would be necessary to fully cover the need for care. Conclusions The number of patients with CKD Stage 3 who would benefit from nephrology care is high. Considering that one patient-year of delay of dialysis could cover a nephrologist’s annual salary, interventions aimed to improve the care of advanced CKD may be economically sound.
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Affiliation(s)
- Massimo Torreggiani
- Department of Nephrology and Dialysis, Centre Hospitalier Le Mans, Le Mans, France
| | - Antoine Chatrenet
- Department of Nephrology and Dialysis, Centre Hospitalier Le Mans, Le Mans, France
| | - Antioco Fois
- Department of Nephrology and Dialysis, Centre Hospitalier Le Mans, Le Mans, France
| | | | - Romain Crochette
- Department of Nephrology and Dialysis, Centre Hospitalier Le Mans, Le Mans, France
| | - Mickael Sigogne
- Department of Nephrology and Dialysis, Centre Hospitalier Le Mans, Le Mans, France
| | - Samuel Wacrenier
- Department of Nephrology and Dialysis, Centre Hospitalier Le Mans, Le Mans, France
| | | | - Béatrice Mazé
- Department of Nephrology and Dialysis, Centre Hospitalier Le Mans, Le Mans, France
| | | | | | - Hafedh Fessi
- Department of Nephrology, Hospital Tenon, Paris, France
| | - Giorgina Barbara Piccoli
- Department of Nephrology and Dialysis, Centre Hospitalier Le Mans, Le Mans, France.,Dipartimento di Scienze Cliniche e Biologiche, Università di Torino, Torino, Italy
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Smekal MD, Bello AK, Donald M, Zaidi D, McBrien K, Nicholson K, Novak E, Hemmelgarn B. Enhancing primary care capacity in chronic kidney disease management: a quality improvement educational initiative. BMJ Open 2021; 11:e046068. [PMID: 34753751 PMCID: PMC8578991 DOI: 10.1136/bmjopen-2020-046068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Gaps in identification, medical management and appropriate referral for patients with chronic kidney disease (CKD) are evident. OBJECTIVE We designed and implemented an interactive educational intervention (accredited workshop) to improve primary care providers' awareness of tools to support guideline-concordant CKD management. DESIGN We used the Kern method to design the educational intervention and targeted the accredited workshops to primary care team members (physicians, nurses and allied health) in Alberta, Canada. We conducted anonymous pre-workshop and post-workshop surveys to identify practice-specific barriers to care, identify potential solutions, and evaluate provider confidence pre-intervention and post-intervention. We used non-parametric statistics to analyse Likert-type survey data and descriptive content analysis to categorise responses to open-ended survey questions. RESULTS We delivered 12 workshops to 114 providers from September 2017 through March 2019. Significant improvements (p<0.001) in confidence to appropriately identify, manage and refer patients with CKD were observed. Participants identified several patient-level, provider-level, and system-level barriers and potential solutions to care for patients with CKD; the majority of these barriers were addressed in the interactive workshop. CONCLUSIONS The Kern model was an effective methodology to design and implement an educational intervention to improve providers' confidence in managing patients with CKD in primary care. Future research is needed to determine if these perceived knowledge and confidence improvements affect patient outcomes and whether improvements are sustained long term.
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Affiliation(s)
| | - Aminu K Bello
- Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Deenaz Zaidi
- Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kerry McBrien
- Family Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Ellen Novak
- Alberta Kidney Care, Alberta Health Services, Calgary, Alberta, Canada
| | - Brenda Hemmelgarn
- Medicine, University of Calgary, Calgary, Alberta, Canada
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Donald M, Smekal MD, Elliott MJ, McBrien K, Weaver RG, Manns BJ, Tonelli M, Bello A, Straus SE, Scott-Douglas N, Jindal K, Hemmelgarn BR. Online clinical pathway for chronic kidney disease management in primary care: a retrospective cohort study. BMC Nephrol 2021; 22:332. [PMID: 34615462 PMCID: PMC8496057 DOI: 10.1186/s12882-021-02533-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 09/09/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Clinical pathways aim to improve patient care. We sought to determine whether an online chronic kidney disease (CKD) clinical pathway was associated with improvements in CKD management. METHODS We conducted a retrospective pre/post population-based cohort study using linked health data from Alberta, Canada. We included adults 18 years or older with mean estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73m2. The primary outcome was measurement of an outpatient urine albumin creatinine ratio (ACR) in a 28-day period, among people without a test in the prior year. Secondary outcomes included use of guideline-recommended drug therapies (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and statins). RESULTS The study period spanned October 2010 to March 2017. There were 84 independent 28-day periods (53 pre, 31 post pathway implementation) including 345,058 adults. The population was predominantly female (56%) with median age 77 years; most had category 3A CKD (67%) and hypertension (82%). In adjusted segmented regression models, the increase in the rate of change of ACR testing was greatest in Calgary zone (adjusted OR 1.19 per year, 95% CI 1.16-1.21), where dissemination of the pathway was strongest; this increase was more pronounced in those without diabetes (adjusted OR 1.25 per year, 95% CI 1.21-1.29). Small improvements in guideline-concordant medication use were also observed. CONCLUSIONS Following implementation of an online CKD clinical pathway, improvements in ACR testing were evident in regions where the pathway was most actively used, particularly among individuals without diabetes.
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Affiliation(s)
- Maoliosa Donald
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Michelle D Smekal
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Meghan J Elliott
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Kerry McBrien
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Robert G Weaver
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Braden J Manns
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Aminu Bello
- Faculty of Medicine & Dentistry, University of Alberta, 2J2.01 Walter C MacKenzie Health Sciences Centre, Clinical Sciences Building, 8440 112 St NW, Edmonton, AB, T6G 2B7, Canada
| | - Sharon E Straus
- Department of Family & Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Nairne Scott-Douglas
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Kailash Jindal
- Faculty of Medicine & Dentistry, University of Alberta, 2J2.01 Walter C MacKenzie Health Sciences Centre, Clinical Sciences Building, 8440 112 St NW, Edmonton, AB, T6G 2B7, Canada
| | - Brenda R Hemmelgarn
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada.
- Faculty of Medicine & Dentistry, University of Alberta, 2J2.01 Walter C MacKenzie Health Sciences Centre, Clinical Sciences Building, 8440 112 St NW, Edmonton, AB, T6G 2B7, Canada.
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Tatematsu S, Kobayashi K, Utsunomiya Y, Isozaki T, Hatta T, Kusumoto T, Miyazaki M, Hatori N, Otani H. Nationwide questionnaire survey on the management of chronic kidney disease for general practitioners in Japan. Clin Exp Nephrol 2021; 25:1093-1102. [PMID: 34251522 DOI: 10.1007/s10157-021-02084-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 05/22/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND In 2019, a nationwide questionnaire survey on the management of chronic kidney disease (CKD) was circulated to general practitioners (GPs) throughout Japan by The Japan Physicians Association. The aim was to assess the current state of CKD medical care in the country and evaluate the utilization of CKD-specific guidelines in the treatment by GPs. METHODS The voluntary survey targeted all members of Japan Physicians Association, a nationwide organization consisting primarily of 15,000 GPs in clinics throughout the country. GPs were divided into groups: 171 GPs using and 414 GPs not using the guidelines. Comparisons between the groups' responses were made using propensity score matching and component cluster analysis. RESULTS Overall responses revealed that the estimated glomerular filtration rate's utilization rate was high (95.1%). However, evidence-practice gaps in urine protein quantification and anemia remedy were prominent. There were significantly favorable answers in terms of CKD management in the user group compared with those in the non-user group, except for the questions about a urine check at the first visit, stopping the use of renin-angiotensin system inhibitors, and the target blood pressure for elderly CKD patients. The differences suggest that utilization of the CKD guidelines has improved CKD management practices by GPs. CONCLUSIONS Further promotion of CKD guidelines utilization (28% in this survey) is considered valid for CKD medical education.
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Affiliation(s)
- Satoru Tatematsu
- Committee of Kidney and Electrolyte Disease, Japan Physicians Association, Tokyo, Japan.,Division of Nephrology, Department of Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Kazuo Kobayashi
- Committee of Kidney and Electrolyte Disease, Japan Physicians Association, Tokyo, Japan. .,Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Kanagawa, Japan.
| | - Yasunori Utsunomiya
- Committee of Kidney and Electrolyte Disease, Japan Physicians Association, Tokyo, Japan
| | - Taisuke Isozaki
- Committee of Kidney and Electrolyte Disease, Japan Physicians Association, Tokyo, Japan
| | - Tsuguru Hatta
- Committee of Kidney and Electrolyte Disease, Japan Physicians Association, Tokyo, Japan
| | - Takuo Kusumoto
- Committee of Kidney and Electrolyte Disease, Japan Physicians Association, Tokyo, Japan
| | - Masanobu Miyazaki
- Committee of Kidney and Electrolyte Disease, Japan Physicians Association, Tokyo, Japan
| | | | - Haruhisa Otani
- Committee of Kidney and Electrolyte Disease, Japan Physicians Association, Tokyo, Japan
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Assessing the Delivery of Coordinated Care to Patients with Advanced Chronic Kidney Disease in Ontario, Canada: A Survey of Patients and Healthcare Professionals. Int J Integr Care 2021; 21:30. [PMID: 34220394 PMCID: PMC8231462 DOI: 10.5334/ijic.5587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Introduction: Patients with advanced Chronic Kidney Disease (CKD) have complex health needs, and thus require care that is coordinated across professionals and organizations. This study aimed to describe the extent of coordinated care delivery for patients with advanced CKD from the perspectives of both patients and healthcare professionals. Methods: The Coordination Scale of the Patient Assessment of Chronic Illness Care (PACIC-26) survey was administered to a random sample of 14,257 patients on maintenance dialysis or receiving care in end-stage kidney disease preparation clinics in Ontario, Canada. A five-item survey was administered to 596 multidisciplinary nephrology professionals. Results: Among the 1,925 patient respondents, 67% reported they had been referred to an allied health professional; 19% had been encouraged to attend programs in the community; and 34% had been told how their visits with other types of doctors helped their treatment (% reporting “always” or “most of the time”). Patient responses were significantly different by treatment modality/setting, but not by gender or geographic location of treatment facility. Among the 276 professional respondents, 37% reported their patients’ care was well-coordinated across settings; 56% reported participating in interdisciplinary care planning discussions; and 53% reported they are aware of appropriate home and community services to support their patients (% reporting “always” or “most of the time”). Conclusion: The results suggest that care for patients with advanced CKD in Ontario is not consistently coordinated. Healthcare professionals may enhance patient perceptions of coordinated care through explicit communication with patients about how the professionals they see and treatments or services they receive influence their overall health and well-being. At a systems level, there is a need to improve professional awareness of and linkages to home- and community-based services.
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Delatorre T, Romão EA, de Mattos ATR, Ferreira JBB. Management of chronic kidney disease: perspectives of Brazilian primary care physicians. Prim Health Care Res Dev 2021; 22:e8. [PMID: 33729114 PMCID: PMC8060812 DOI: 10.1017/s1463423621000074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 12/09/2020] [Accepted: 01/08/2021] [Indexed: 11/20/2022] Open
Abstract
AIM To investigate primary care physicians' knowledge of and attitudes toward care for chronic kidney disease patients. BACKGROUND In Brazil, care for chronic kidney disease, a global public health problem, is provided by the Brazilian National Health System, which is organized around primary care. The study aimed to investigate the knowledge and attitudes of primary care physicians about the management of chronic kidney disease. METHOD This research is based on quantitative and qualitative data. The participants were 92 physicians from 81 primary care units located in eight cities of the São Paulo/Brazil health region, who answered a self-administered questionnaire. FINDINGS Only 59% and 58% of the physicians recognized smoking and obesity, respectively, as risk factors for chronic kidney disease. Health appointments and drug therapy predominated as disease prevention strategies and less than 30% mentioned multiprofessional care and health education groups. For early diagnosis, isolated serum creatinine was the most used test and 64.6% stated they classified the disease stages. Exclusive follow-up in primary care decreased from 79% in stage 1 to 19.5% in stage 3B and the patients' monitoring in the healthcare network varied from 8.7% in stage 1 to 70.6% in stages 4 and 5ND, suggesting early referrals and lack of referral at the necessary stages. Access to information on the referred patient was, predominantly, through the patient's report and 74% of the physicians did not have matrix support regarding chronic kidney disease. CONCLUSION The study showed that the healthcare teams need to update their knowledge and procedures to be able to provide a comprehensive and efficient approach to treating chronic kidney disease in primary care.
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Affiliation(s)
- Thatiane Delatorre
- Social Medicine Department of the Medical School of Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Elen A. Romão
- Medical Clinic Department of the Medical School of Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | | | - Janise B. B. Ferreira
- Social Medicine Department of the Medical School of Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
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Brito CP, Moraes IG, Luders C, de Brito CMM, Yamaguti WP. Relationship of phase angle and peak torque of knee extensors with the performance in six-minute step test in haemodialysis patients. BMC Nephrol 2021; 22:56. [PMID: 33557771 PMCID: PMC7869460 DOI: 10.1186/s12882-021-02256-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 01/25/2021] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Chronic kidney disease is a systemic disease affecting not only renal function, but also endocrine, cardiovascular, and skeletal muscle systems, with broad impact on functionality. Therefore, the assessment of body composition, peripheral muscle function, and exercise tolerance is also of great importance in this population. In addition, the development of reliable strategies that use feasible tools in clinical practice is of great importance in the functional diagnosis, clinical management and prescription of physical activity. OBJECTIVE To assess the relationship between phase angle and peak torque of knee extensors with the performance in six-minute step test of patients with chronic kidney disease undergoing haemodialysis. METHODS Observational and cross-sectional study at Haemodialysis Centre of Sírio-Libanês Hospital. The evaluations took place 3 days before the haemodialysis sessions. On the first day, patients underwent anthropometric evaluation and biochemical tests (lactate, urea, creatinine, albumin, ferritin and growth factor similar to insulin type 1 [IGF1]). On the second day, performed electrical bioimpedance and exercise tolerance assessed using the six-minute step test. On the last day, the evaluation of knee extensor muscles strength using isokinetic dynamometry was performed. RESULTS Eighteen subjects were included, with a mean age of 62.3 ± 17.6 years. A positive linear correlation was observed between the phase angle, derived from the electrical bioimpedance, and the performance in six-minute step test in these patients. It was also possible to observe a linear correlation between phase angle and IGF1, handgrip strength, peak torque of knee extensors and quality of life questionnaire. The peak torque of knee extensors also presented a linear correlation with IGF1, the performance in six-minute step test and mal-nutrition and inflammation score. CONCLUSION Phase angle and peak torque of knee extensors were correlated with the performance in six-minute step test. Therefore, the phase angle seems to be an important marker of reduced peripheral muscle function and exercise tolerance in haemodialysis patients.
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Affiliation(s)
- Camila Porto Brito
- Hospital Sírio-Libanês, Rehabilitation Centre, Dona Adma Jafet Street, 91 - Bela Vista, São Paulo, SP, 01308-050, Brazil
| | - Igor Gutierrez Moraes
- Hospital Sírio-Libanês, Rehabilitation Centre, Dona Adma Jafet Street, 91 - Bela Vista, São Paulo, SP, 01308-050, Brazil
| | - Cláudio Luders
- Hospital Sírio-Libanês, Haemodialysis Centre, Dona Adma Jafet, 91 - Bela Vista, São Paulo, SP, 01308-050, Brazil
| | - Christina May Moran de Brito
- Hospital Sírio-Libanês, Rehabilitation Centre, Dona Adma Jafet Street, 91 - Bela Vista, São Paulo, SP, 01308-050, Brazil
| | - Wellington Pereira Yamaguti
- Hospital Sírio-Libanês, Rehabilitation Centre, Dona Adma Jafet Street, 91 - Bela Vista, São Paulo, SP, 01308-050, Brazil.
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Lin CC, Hwang SJ. Patient-Centered Self-Management in Patients with Chronic Kidney Disease: Challenges and Implications. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E9443. [PMID: 33339300 PMCID: PMC7766278 DOI: 10.3390/ijerph17249443] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/04/2020] [Accepted: 12/15/2020] [Indexed: 11/17/2022]
Abstract
This review aims to identify attributes of patient-centered self-management (PCSM) in the current literature and explore its implementation in resolving patient obstacles in chronic kidney disease (CKD) treatment and management. A search of relevant articles and literature on PCSM, integrated care, and challenges of CKD management was conducted. Vital attributes of PCSM and current self-management interventions employed to resolve patient obstacles in CKD management were identified from inclusion studies. Findings affirm that PCSM strategies have positive effects on CKD management, but a lack of quality primary study, and long-term evidence presents the need for further development. Future research should focus on the development of a standardized and universal integrated PCSM model and a uniform system of data collection in the clinical setting. The difficulty of CKD management lies in how it is a comorbid and progressive disease. A pure biomedical approach is inadequate. Our review recommends that an integrated PCSM approach with health literacy and information technology intervention, which unifies and integrates patient education, can address the difficulties that are contributing to unsuccessful treatment outcomes. An integrated PCSM model should be implemented systematically and methodologically into future CKD management and health policies.
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Affiliation(s)
- Chiu-Chu Lin
- School of Nursing, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Department of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Shang-Jyh Hwang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan;
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Taiwan Society of Nephrology, Taipei 10022, Taiwan
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Thomas N, Nation M, Woolnough L, Gallagher H. Quality improvement at scale: evaluation of the drivers and barriers to adoption and sustainability of an intervention to reduce late referral in chronic kidney disease. BMJ Open Qual 2020; 9:bmjoq-2020-001045. [PMID: 33184043 PMCID: PMC7662418 DOI: 10.1136/bmjoq-2020-001045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 10/15/2020] [Accepted: 10/26/2020] [Indexed: 12/05/2022] Open
Abstract
This quality improvement project aimed to drive large scale and sustained change to reduce the burden of chronic kidney disease in the UK. The intervention is a software program that extracts relevant biochemical data from laboratory databases which then generate graphs of estimated kidney function (eGFR) over time. Graphs showing progressive kidney disease are sent directly back to general practitioners (GPs) to alert them to rereview patient care and if necessary, refer to renal services. The aim of this evaluation study was to explain the barriers and drivers to implementation and adoption of the eGFR graph intervention. This evaluation study involved 5 of the 20 participating renal units (sites). A developmental evaluation approach was used. Methods included collection of descriptive data about graph reporting; GP surveys (n=68); focus groups (n=4) with practices; face-to-face interviews with secondary care clinicians (n=10). Results showed the mean number of graphs reviewed per week per site was 230, taking 1 hour per week per site. Only 18.2% graphs highlighted a concerning decline in kidney function. Important enablers to sustain the intervention were low cost, easy to understand, a sense of local ownership and perceived impact. Barriers included nephrologists’ perceived increase in new referrals. We concluded that developmental evaluation can explain the barriers/drivers to implementation of a national quality improvement project that involves a variety of different stakeholders. The intervention has the potential to slow down progression of kidney disease due to the eGFR prompts alerting GPs to review the patient record and take action, such as reviewing medications and referring to renal teams if progressive kidney disease had not been identified previously.
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Affiliation(s)
- Nicola Thomas
- School of Health and Social Care, London South Bank University, London, UK
| | | | | | - Hugh Gallagher
- Epsom and St. Helier University Hospitals NHS Trust, Carshalton, UK
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